White Rock Medical Center

All Charges

Charge

Type

Setting

Price

Helicobacter pylori, IgM Ab SO

Facility

$216.00

Service Code	CPT 86677
Hospital Charge Code	1604990
Hospital Revenue Code	302
Rate for Payer: Cash Price	$190.08

Helicobacter pylori, IgM Ab SO

Facility

$216.00

Service Code	CPT 86677
Hospital Charge Code	1604990
Hospital Revenue Code	302
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna Commercial	$17.69
Rate for Payer: Aetna Medicare	$25.28
Rate for Payer: Amerigroup CHIP/Medicaid	$6.57
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$16.85
Rate for Payer: Amerigroup Medicare	$16.85
Rate for Payer: BCBS of TX Blue Advantage	$27.80
Rate for Payer: BCBS of TX Blue Essentials	$33.36
Rate for Payer: BCBS of TX Medicare	$16.85
Rate for Payer: BCBS of TX PPO	$37.24
Rate for Payer: Cash Price	$190.08
Rate for Payer: Cash Price	$190.08
Rate for Payer: Cigna Medicaid	$16.85
Rate for Payer: Cigna Medicare	$16.85
Rate for Payer: Employer Direct Commercial	$16.85
Rate for Payer: Humana Medicare/TRICARE	$16.85
Rate for Payer: Molina CHIP/Medicaid	$16.85
Rate for Payer: Molina Dual Medicare/Medicaid	$16.85
Rate for Payer: Molina Medicare	$16.85
Rate for Payer: Multiplan Auto	$140.40
Rate for Payer: Multiplan Commercial	$140.40
Rate for Payer: Multiplan Workers Comp	$140.40
Rate for Payer: Parkland Medicaid	$16.85
Rate for Payer: Scott and White EPO/PPO	$21.06
Rate for Payer: Scott and White Medicare	$16.85
Rate for Payer: Superior Health Plan CHIP/Medicaid	$16.85
Rate for Payer: Superior Health Plan EPO	$16.85
Rate for Payer: Superior Health Plan Medicare	$16.85
Rate for Payer: Universal American Dual Medicare/Medicaid	$16.85
Rate for Payer: Universal American Medicare	$16.85
Rate for Payer: Wellcare Medicare	$16.85
Rate for Payer: Wellmed Medicare	$16.85

HELIX, TISSUE 165CM X 2.8MM OD -- DHF

Facility

$1,042.68

Hospital Charge Code	80811680
Hospital Revenue Code	272
Min. Negotiated Rate	$93.84
Max. Negotiated Rate	$677.74
Rate for Payer: Aetna Commercial	$573.47
Rate for Payer: Amerigroup CHIP/Medicaid	$93.84
Rate for Payer: BCBS of TX Blue Advantage	$312.80
Rate for Payer: BCBS of TX Blue Essentials	$375.36
Rate for Payer: BCBS of TX PPO	$417.07
Rate for Payer: Cash Price	$917.56
Rate for Payer: Multiplan Auto	$677.74
Rate for Payer: Multiplan Commercial	$677.74
Rate for Payer: Multiplan Workers Comp	$677.74
Rate for Payer: Scott and White EPO/PPO	$521.34
Rate for Payer: Superior Health Plan EPO	$141.80

HELIX, TISSUE 165CM X 2.8MM OD -- DHF

Facility

$1,042.68

Hospital Charge Code	80811680
Hospital Revenue Code	272
Rate for Payer: Cash Price	$917.56

Helper T-Lymph-CD4 SO

Facility

$169.00

Service Code	CPT 86361
Hospital Charge Code	1700319
Hospital Revenue Code	302
Rate for Payer: Cash Price	$148.72

Helper T-Lymph-CD4 SO

Facility

$169.00

Service Code	CPT 86361
Hospital Charge Code	1700319
Hospital Revenue Code	302
Min. Negotiated Rate	$10.44
Max. Negotiated Rate	$109.85
Rate for Payer: Aetna Commercial	$28.12
Rate for Payer: Aetna Medicare	$40.17
Rate for Payer: Amerigroup CHIP/Medicaid	$10.44
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$26.78
Rate for Payer: Amerigroup Medicare	$26.78
Rate for Payer: BCBS of TX Blue Advantage	$44.19
Rate for Payer: BCBS of TX Blue Essentials	$53.02
Rate for Payer: BCBS of TX Medicare	$26.78
Rate for Payer: BCBS of TX PPO	$59.18
Rate for Payer: Cash Price	$148.72
Rate for Payer: Cash Price	$148.72
Rate for Payer: Cigna Medicaid	$26.78
Rate for Payer: Cigna Medicare	$26.78
Rate for Payer: Employer Direct Commercial	$26.78
Rate for Payer: Humana Medicare/TRICARE	$26.78
Rate for Payer: Molina CHIP/Medicaid	$26.78
Rate for Payer: Molina Dual Medicare/Medicaid	$26.78
Rate for Payer: Molina Medicare	$26.78
Rate for Payer: Multiplan Auto	$109.85
Rate for Payer: Multiplan Commercial	$109.85
Rate for Payer: Multiplan Workers Comp	$109.85
Rate for Payer: Parkland Medicaid	$26.78
Rate for Payer: Scott and White EPO/PPO	$33.48
Rate for Payer: Scott and White Medicare	$26.78
Rate for Payer: Superior Health Plan CHIP/Medicaid	$26.78
Rate for Payer: Superior Health Plan EPO	$26.78
Rate for Payer: Superior Health Plan Medicare	$26.78
Rate for Payer: Universal American Dual Medicare/Medicaid	$26.78
Rate for Payer: Universal American Medicare	$26.78
Rate for Payer: Wellcare Medicare	$26.78
Rate for Payer: Wellmed Medicare	$26.78

Hematocrit

Facility

$97.00

Service Code	CPT 85014
Hospital Charge Code	1600493
Hospital Revenue Code	305
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$63.05
Rate for Payer: Aetna Commercial	$2.48
Rate for Payer: Aetna Medicare	$3.56
Rate for Payer: Amerigroup CHIP/Medicaid	$0.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.37
Rate for Payer: Amerigroup Medicare	$2.37
Rate for Payer: BCBS of TX Blue Advantage	$3.91
Rate for Payer: BCBS of TX Blue Essentials	$4.69
Rate for Payer: BCBS of TX Medicare	$2.37
Rate for Payer: BCBS of TX PPO	$5.24
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cigna Medicaid	$2.37
Rate for Payer: Cigna Medicare	$2.37
Rate for Payer: Employer Direct Commercial	$2.37
Rate for Payer: Humana Medicare/TRICARE	$2.37
Rate for Payer: Molina CHIP/Medicaid	$2.37
Rate for Payer: Molina Dual Medicare/Medicaid	$2.37
Rate for Payer: Molina Medicare	$2.37
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$2.37
Rate for Payer: Scott and White EPO/PPO	$2.96
Rate for Payer: Scott and White Medicare	$2.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.37
Rate for Payer: Superior Health Plan EPO	$2.37
Rate for Payer: Superior Health Plan Medicare	$2.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.37
Rate for Payer: Universal American Medicare	$2.37
Rate for Payer: Wellcare Medicare	$2.37
Rate for Payer: Wellmed Medicare	$2.37

Hematocrit (POCT)

Facility

$97.00

Service Code	CPT 85014
Hospital Charge Code	1690002
Hospital Revenue Code	305
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$63.05
Rate for Payer: Aetna Commercial	$2.48
Rate for Payer: Aetna Medicare	$3.56
Rate for Payer: Amerigroup CHIP/Medicaid	$0.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.37
Rate for Payer: Amerigroup Medicare	$2.37
Rate for Payer: BCBS of TX Blue Advantage	$3.91
Rate for Payer: BCBS of TX Blue Essentials	$4.69
Rate for Payer: BCBS of TX Medicare	$2.37
Rate for Payer: BCBS of TX PPO	$5.24
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cigna Medicaid	$2.37
Rate for Payer: Cigna Medicare	$2.37
Rate for Payer: Employer Direct Commercial	$2.37
Rate for Payer: Humana Medicare/TRICARE	$2.37
Rate for Payer: Molina CHIP/Medicaid	$2.37
Rate for Payer: Molina Dual Medicare/Medicaid	$2.37
Rate for Payer: Molina Medicare	$2.37
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$2.37
Rate for Payer: Scott and White EPO/PPO	$2.96
Rate for Payer: Scott and White Medicare	$2.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.37
Rate for Payer: Superior Health Plan EPO	$2.37
Rate for Payer: Superior Health Plan Medicare	$2.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.37
Rate for Payer: Universal American Medicare	$2.37
Rate for Payer: Wellcare Medicare	$2.37
Rate for Payer: Wellmed Medicare	$2.37

Hematocrit (POCT) BCE

Facility

$97.00

Service Code	CPT 85014
Hospital Charge Code	1690002
Hospital Revenue Code	305
Rate for Payer: Cash Price	$85.36

Hematocrit (POCT) BCE

Facility

$97.00

Service Code	CPT 85014
Hospital Charge Code	1690002
Hospital Revenue Code	305
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$63.05
Rate for Payer: Aetna Commercial	$2.48
Rate for Payer: Aetna Medicare	$3.56
Rate for Payer: Amerigroup CHIP/Medicaid	$0.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.37
Rate for Payer: Amerigroup Medicare	$2.37
Rate for Payer: BCBS of TX Blue Advantage	$3.91
Rate for Payer: BCBS of TX Blue Essentials	$4.69
Rate for Payer: BCBS of TX Medicare	$2.37
Rate for Payer: BCBS of TX PPO	$5.24
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cigna Medicaid	$2.37
Rate for Payer: Cigna Medicare	$2.37
Rate for Payer: Employer Direct Commercial	$2.37
Rate for Payer: Humana Medicare/TRICARE	$2.37
Rate for Payer: Molina CHIP/Medicaid	$2.37
Rate for Payer: Molina Dual Medicare/Medicaid	$2.37
Rate for Payer: Molina Medicare	$2.37
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$2.37
Rate for Payer: Scott and White EPO/PPO	$2.96
Rate for Payer: Scott and White Medicare	$2.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.37
Rate for Payer: Superior Health Plan EPO	$2.37
Rate for Payer: Superior Health Plan Medicare	$2.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.37
Rate for Payer: Universal American Medicare	$2.37
Rate for Payer: Wellcare Medicare	$2.37
Rate for Payer: Wellmed Medicare	$2.37

Hematocrit SO

Facility

$97.00

Service Code	CPT 85014
Hospital Charge Code	1600493
Hospital Revenue Code	305
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$63.05
Rate for Payer: Aetna Commercial	$2.48
Rate for Payer: Aetna Medicare	$3.56
Rate for Payer: Amerigroup CHIP/Medicaid	$0.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.37
Rate for Payer: Amerigroup Medicare	$2.37
Rate for Payer: BCBS of TX Blue Advantage	$3.91
Rate for Payer: BCBS of TX Blue Essentials	$4.69
Rate for Payer: BCBS of TX Medicare	$2.37
Rate for Payer: BCBS of TX PPO	$5.24
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cash Price	$85.36
Rate for Payer: Cigna Medicaid	$2.37
Rate for Payer: Cigna Medicare	$2.37
Rate for Payer: Employer Direct Commercial	$2.37
Rate for Payer: Humana Medicare/TRICARE	$2.37
Rate for Payer: Molina CHIP/Medicaid	$2.37
Rate for Payer: Molina Dual Medicare/Medicaid	$2.37
Rate for Payer: Molina Medicare	$2.37
Rate for Payer: Multiplan Auto	$63.05
Rate for Payer: Multiplan Commercial	$63.05
Rate for Payer: Multiplan Workers Comp	$63.05
Rate for Payer: Parkland Medicaid	$2.37
Rate for Payer: Scott and White EPO/PPO	$2.96
Rate for Payer: Scott and White Medicare	$2.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.37
Rate for Payer: Superior Health Plan EPO	$2.37
Rate for Payer: Superior Health Plan Medicare	$2.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.37
Rate for Payer: Universal American Medicare	$2.37
Rate for Payer: Wellcare Medicare	$2.37
Rate for Payer: Wellmed Medicare	$2.37

Hematocrit SO

Facility

$97.00

Service Code	CPT 85014
Hospital Charge Code	1600493
Hospital Revenue Code	305
Rate for Payer: Cash Price	$85.36

Hemiphalangectomy or interphalangeal joint excision, toe, proximal end of phalanx, each

Facility

$10,000.00

Service Code	CPT 28160
Hospital Charge Code	36028160
Hospital Revenue Code	360
Min. Negotiated Rate	$65.29
Max. Negotiated Rate	$10,000.00
Rate for Payer: Aetna Commercial	$3,090.00
Rate for Payer: Aetna Medicare	$4,440.36
Rate for Payer: Amerigroup CHIP/Medicaid	$1,088.27
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Amerigroup Medicare	$2,960.24
Rate for Payer: BCBS of TX Blue Advantage	$4,571.54
Rate for Payer: BCBS of TX Blue Essentials	$5,474.90
Rate for Payer: BCBS of TX Medicare	$2,960.24
Rate for Payer: BCBS of TX PPO	$6,898.37
Rate for Payer: Cigna Commercial	$6,705.80
Rate for Payer: Cigna Medicaid	$1,088.27
Rate for Payer: Cigna Medicare	$2,960.24
Rate for Payer: Employer Direct Commercial	$2,960.24
Rate for Payer: Humana Medicare/TRICARE	$2,960.24
Rate for Payer: Molina CHIP/Medicaid	$1,088.27
Rate for Payer: Molina Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Molina Medicare	$2,960.24
Rate for Payer: Multiplan Auto	$10,000.00
Rate for Payer: Multiplan Commercial	$10,000.00
Rate for Payer: Multiplan Workers Comp	$10,000.00
Rate for Payer: Parkland Medicaid	$1,088.27
Rate for Payer: Scott and White EPO/PPO	$65.29
Rate for Payer: Scott and White Medicare	$2,960.24
Rate for Payer: Superior Health Plan CHIP/Medicaid	$1,088.27
Rate for Payer: Superior Health Plan EPO	$2,960.24
Rate for Payer: Superior Health Plan Medicare	$2,960.24
Rate for Payer: Universal American Dual Medicare/Medicaid	$2,960.24
Rate for Payer: Universal American Medicare	$2,960.24
Rate for Payer: Wellcare Medicare	$2,960.24
Rate for Payer: Wellmed Medicare	$2,960.24

Hemodialysis Treatment Complete Inpatient BCE

Facility

$4,750.00

Hospital Charge Code	800011
Hospital Revenue Code	801
Min. Negotiated Rate	$427.50
Max. Negotiated Rate	$3,087.50
Rate for Payer: Aetna Commercial	$2,612.50
Rate for Payer: Amerigroup CHIP/Medicaid	$427.50
Rate for Payer: BCBS of TX Blue Advantage	$1,425.00
Rate for Payer: BCBS of TX Blue Essentials	$1,710.00
Rate for Payer: BCBS of TX PPO	$1,900.00
Rate for Payer: Cash Price	$4,180.00
Rate for Payer: Multiplan Auto	$3,087.50
Rate for Payer: Multiplan Commercial	$3,087.50
Rate for Payer: Multiplan Workers Comp	$3,087.50
Rate for Payer: Scott and White EPO/PPO	$2,375.00
Rate for Payer: Superior Health Plan EPO	$646.00

Hemodialysis Treatment Complete Inpatient BCE

Facility

$4,750.00

Hospital Charge Code	800011
Hospital Revenue Code	801
Rate for Payer: Cash Price	$4,180.00

Hemodialysis Treatment Complete Outpatient BCE

Facility

$2,811.00

Service Code	CPT 90935
Hospital Charge Code	800029
Hospital Revenue Code	829
Rate for Payer: Cash Price	$2,473.68

Hemodialysis Treatment Complete Outpatient BCE

Facility

$2,811.00

Service Code	CPT 90935
Hospital Charge Code	800029
Hospital Revenue Code	829
Min. Negotiated Rate	$11.43
Max. Negotiated Rate	$1,827.15
Rate for Payer: Aetna Commercial	$94.88
Rate for Payer: Aetna Medicare	$958.62
Rate for Payer: Amerigroup CHIP/Medicaid	$252.99
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$639.08
Rate for Payer: Amerigroup Medicare	$639.08
Rate for Payer: BCBS of TX Blue Advantage	$843.30
Rate for Payer: BCBS of TX Blue Essentials	$1,011.96
Rate for Payer: BCBS of TX Medicare	$639.08
Rate for Payer: BCBS of TX PPO	$1,124.40
Rate for Payer: Cash Price	$2,473.68
Rate for Payer: Cash Price	$2,473.68
Rate for Payer: Cash Price	$2,473.68
Rate for Payer: Cigna Commercial	$1,447.70
Rate for Payer: Cigna Medicare	$639.08
Rate for Payer: Employer Direct Commercial	$639.08
Rate for Payer: Humana Medicare/TRICARE	$639.08
Rate for Payer: Molina Dual Medicare/Medicaid	$639.08
Rate for Payer: Molina Medicare	$639.08
Rate for Payer: Multiplan Auto	$1,827.15
Rate for Payer: Multiplan Commercial	$1,827.15
Rate for Payer: Multiplan Workers Comp	$1,827.15
Rate for Payer: Scott and White EPO/PPO	$11.43
Rate for Payer: Scott and White Medicare	$639.08
Rate for Payer: Superior Health Plan EPO	$639.08
Rate for Payer: Superior Health Plan Medicare	$639.08
Rate for Payer: Universal American Dual Medicare/Medicaid	$639.08
Rate for Payer: Universal American Medicare	$639.08
Rate for Payer: Wellcare Medicare	$639.08
Rate for Payer: Wellmed Medicare	$639.08

Hemoglobin

Facility

$98.00

Service Code	CPT 85018
Hospital Charge Code	1600501
Hospital Revenue Code	305
Rate for Payer: Cash Price	$86.24

Hemoglobin

Facility

$98.00

Service Code	CPT 85018
Hospital Charge Code	1600501
Hospital Revenue Code	305
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$63.70
Rate for Payer: Aetna Commercial	$2.48
Rate for Payer: Aetna Medicare	$3.56
Rate for Payer: Amerigroup CHIP/Medicaid	$0.92
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$2.37
Rate for Payer: Amerigroup Medicare	$2.37
Rate for Payer: BCBS of TX Blue Advantage	$3.91
Rate for Payer: BCBS of TX Blue Essentials	$4.69
Rate for Payer: BCBS of TX Medicare	$2.37
Rate for Payer: BCBS of TX PPO	$5.24
Rate for Payer: Cash Price	$86.24
Rate for Payer: Cash Price	$86.24
Rate for Payer: Cigna Medicaid	$2.37
Rate for Payer: Cigna Medicare	$2.37
Rate for Payer: Employer Direct Commercial	$2.37
Rate for Payer: Humana Medicare/TRICARE	$2.37
Rate for Payer: Molina CHIP/Medicaid	$2.37
Rate for Payer: Molina Dual Medicare/Medicaid	$2.37
Rate for Payer: Molina Medicare	$2.37
Rate for Payer: Multiplan Auto	$63.70
Rate for Payer: Multiplan Commercial	$63.70
Rate for Payer: Multiplan Workers Comp	$63.70
Rate for Payer: Parkland Medicaid	$2.37
Rate for Payer: Scott and White EPO/PPO	$2.96
Rate for Payer: Scott and White Medicare	$2.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$2.37
Rate for Payer: Superior Health Plan EPO	$2.37
Rate for Payer: Superior Health Plan Medicare	$2.37
Rate for Payer: Universal American Dual Medicare/Medicaid	$2.37
Rate for Payer: Universal American Medicare	$2.37
Rate for Payer: Wellcare Medicare	$2.37
Rate for Payer: Wellmed Medicare	$2.37

Hemoglobin A1C

Facility

$279.00

Service Code	CPT 83036
Hospital Charge Code	1602176
Hospital Revenue Code	301
Rate for Payer: Cash Price	$245.52

Hemoglobin A1C

Facility

$279.00

Service Code	CPT 83036
Hospital Charge Code	1602176
Hospital Revenue Code	301
Min. Negotiated Rate	$3.79
Max. Negotiated Rate	$181.35
Rate for Payer: Aetna Commercial	$10.20
Rate for Payer: Aetna Medicare	$14.56
Rate for Payer: Amerigroup CHIP/Medicaid	$3.79
Rate for Payer: Amerigroup Dual Medicare/Medicaid	$9.71
Rate for Payer: Amerigroup Medicare	$9.71
Rate for Payer: BCBS of TX Blue Advantage	$16.02
Rate for Payer: BCBS of TX Blue Essentials	$19.23
Rate for Payer: BCBS of TX Medicare	$9.71
Rate for Payer: BCBS of TX PPO	$21.46
Rate for Payer: Cash Price	$245.52
Rate for Payer: Cash Price	$245.52
Rate for Payer: Cigna Medicaid	$9.71
Rate for Payer: Cigna Medicare	$9.71
Rate for Payer: Employer Direct Commercial	$9.71
Rate for Payer: Humana Medicare/TRICARE	$9.71
Rate for Payer: Molina CHIP/Medicaid	$9.71
Rate for Payer: Molina Dual Medicare/Medicaid	$9.71
Rate for Payer: Molina Medicare	$9.71
Rate for Payer: Multiplan Auto	$181.35
Rate for Payer: Multiplan Commercial	$181.35
Rate for Payer: Multiplan Workers Comp	$181.35
Rate for Payer: Parkland Medicaid	$9.71
Rate for Payer: Scott and White EPO/PPO	$12.14
Rate for Payer: Scott and White Medicare	$9.71
Rate for Payer: Superior Health Plan CHIP/Medicaid	$9.71
Rate for Payer: Superior Health Plan EPO	$9.71
Rate for Payer: Superior Health Plan Medicare	$9.71
Rate for Payer: Universal American Dual Medicare/Medicaid	$9.71
Rate for Payer: Universal American Medicare	$9.71
Rate for Payer: Wellcare Medicare	$9.71
Rate for Payer: Wellmed Medicare	$9.71

HEMOSTAT, ABSORBABLE 4'''' X 4'''' STERILE -- DHF

Facility

$530.59

Hospital Charge Code	81845000
Hospital Revenue Code	270
Rate for Payer: Cash Price	$466.92

HEMOSTAT, ABSORBABLE 4'''' X 4'''' STERILE -- DHF

Facility

$530.59

Hospital Charge Code	81845000
Hospital Revenue Code	270
Min. Negotiated Rate	$47.75
Max. Negotiated Rate	$344.88
Rate for Payer: Aetna Commercial	$291.82
Rate for Payer: Amerigroup CHIP/Medicaid	$47.75
Rate for Payer: BCBS of TX Blue Advantage	$159.18
Rate for Payer: BCBS of TX Blue Essentials	$191.01
Rate for Payer: BCBS of TX PPO	$212.24
Rate for Payer: Cash Price	$466.92
Rate for Payer: Multiplan Auto	$344.88
Rate for Payer: Multiplan Commercial	$344.88
Rate for Payer: Multiplan Workers Comp	$344.88
Rate for Payer: Scott and White EPO/PPO	$265.30
Rate for Payer: Superior Health Plan EPO	$72.16

HEMOSTAT, ABSORBABLE SURG NON-WOVEN MATERIAL 1''''X2'''' -- DHF

Facility

$209.72

Hospital Charge Code	80324296
Hospital Revenue Code	272
Rate for Payer: Cash Price	$184.55

HEMOSTAT, ABSORBABLE SURG NON-WOVEN MATERIAL 1''''X2'''' -- DHF

Facility

$209.72

Hospital Charge Code	80324296
Hospital Revenue Code	272
Min. Negotiated Rate	$18.87
Max. Negotiated Rate	$136.32
Rate for Payer: Aetna Commercial	$115.35
Rate for Payer: Amerigroup CHIP/Medicaid	$18.87
Rate for Payer: BCBS of TX Blue Advantage	$62.92
Rate for Payer: BCBS of TX Blue Essentials	$75.50
Rate for Payer: BCBS of TX PPO	$83.89
Rate for Payer: Cash Price	$184.55
Rate for Payer: Multiplan Auto	$136.32
Rate for Payer: Multiplan Commercial	$136.32
Rate for Payer: Multiplan Workers Comp	$136.32
Rate for Payer: Scott and White EPO/PPO	$104.86
Rate for Payer: Superior Health Plan EPO	$28.52

Know your out-of-pocket cost for care.

All Charges